[DATE]

[MEMBER NAME]

[MEMBER ADDRESS]

Dear [MEMBER NAME]:

As your HealthPartners® Inspire Care Coordinator, I am writing to you today regarding your health risk survey. Please complete and return in the envelope provided. If you prefer to have someone come to your home and complete the survey with you, please call me so a visit can be arranged.

We encourage you to take advantage of these important services:

An annual physical exam with your doctor. These visits are a simple and important way you can maintain your good health.

An annual flu shot, an important part of your regular health care, can be taken care of during your annual exam.

An annual dental exam, an important part of taking care of your health.

We are committed to providing you the best possible support in a way that works for you. If at any time you would like to work with a different Care Coordinator you may call

[XXX-XXX-XXXX] and ask to speak with a Supervisor.

If you have questions, need more information, or would like to set up an in-person meeting to talk about your care, please call either of the numbers listed below.

We look forward to talking with you soon.

This information is available in other forms to people with disabilities by calling HealthPartners Member Services at 952-967-7998 or toll free at 1-866-885-8880, Monday –Friday, 8:00 a.m.-5:00 p.m. TTY users call 952-883-6060 (TTY) or 1-800-443-0156 (toll free TTY).

Sincerely,

[CARE COORDINATOR NAME]

HealthPartners® Inspire Care Coordinator

Phone: [XXX-XXX-XXXX]

Toll Free: [XXX-XXX-XXXX]

Enclosures:

Statement of Nondiscrimination for Health Plan Members, Language Block, Health Assessment, Self-addressed Stamped Envelope

HPCare_98753_01 Approved 8/23/2016

DHS-3428H-ENG 8-18

Minnesota Health Risk Assessment Form

Filling in this form

DHS-3428H-ENG	8-18

Minnesota Health Risk Assessment Form

Note: Fields with * are required in MMIS

Section A

MEMBER LAST NAME*	MEMBER FIRST NAME*	MI*	RECIPIENT ID/PMI NUMBER*
HEALTH PLAN REFERENCE NUMBER (For care coordinator's use)	WHAT IS YOUR DATE OF BIRTH?*	REFERRAL DATE* (For care coordinator's use)
TYPE OF ACTIVITY* (For care coordinator's use) 01 - Telephone screen/Mailed survey 02 - Face to face assessment 05 - Care coordinator change 07 – Administrative activity	WHEN DID YOU COMPLETE THIS INTERVIEW?*	CARE COORDINATOR UMPI NUMBER*
Identify these counties.* For LTCC, indicate health plan performing the assessment. (For care coordinator's use) (COS) (COR) (CFR) (LTCC)

Section B

Who do you currently live with? (Required for SNBC members*)

- Living alone

- Living with spouse or parents

- Living with family, friend or significant other 4	- Living in group setting

- Homeless

- Would live alone or be homeless without current housing type

Assessment team* (For care coordinator's use)

- Health Plan

- County Subcontracting for Health Plan

What is your current housing situation? (Required for SNBC members*)

- Homeless

- Institutional - ICF/DD 03 - Institution - Hospital 04 - Board and Lodge

05 - Foster Care

09 - Own Home/Apartment 11 - Institution - NF/CBC

12 - Non-certified boarding care 16 - Correctional facility

Do you have any current dental concerns?*

Yes No

Chose not to answer

COMMENTS

Do you have a dentist?*

Yes No

Chose not to answer

COMMENTS

Section C

Dressing

How well are you able to manage dressing?* By dressing, we mean laying out the clothes and putting them on, including shoes, and fastening clothes. Would you say that you:

00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Grooming

How well are you able to manage with grooming activities such as combing your hair, putting on makeup, shaving, and brushing your teeth?* Would you say that you:

00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Bathing

How well can you bathe or shower yourself?* Bathing or showering by yourself means washing all parts of the body including your hair and face. Would you say that you:

00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Eating

How well can you manage eating by yourself?* Eating by yourself means drinking, eating and cutting most foods on your own. Would you say that you:

00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Bed Mobility

How well can you manage sitting up or moving around in bed? * Would you say that you: 00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Transferring

How well can you get in and out of a bed or chair?* Would you say that you: 00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Walking

How well are you able to walk around, either without any help or with a cane or walker, but not including a wheelchair?* (Independence in walking refers to the ability to walk short distances around the house. Independence in walking does not include climbing stairs.) Would you say that you:

00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Emotional Health

How would you rate your emotional health?* 00 - No response

- Poor

- Fair

- Good

-Excellent

12 - Chose not to answer

In the past three months, have you been stressed or anxious? Yes No Chose not to answer

In the past three months, have you had little interest or pleasure in doing things that you normally like? Yes No Chose not to answer

In the past three months, have you been feeling down, depressed, or "blue" more than usual? Yes No Chose not to answer

In the past three months have you been limited in your social activities with family, friends, neighbors, or groups (not related to transportation)?

Yes No Chose not to answer

Alcohol/Tobacco/Substance Use

Do you use any substances, such as, but not limited to, alcohol, marijuana, cocaine or amphetamines?

Yes No

Chose not to answer

COMMENTS

Do you have any concerns about your use?

No concerns

Yes, have concerns met by current supports Yes, have concerns not met by current supports Chose not to answer

COMMENTS Do you use tobacco products (includes cigarettes, cigars and smokeless tobacco)? Yes – If yes, would you like information on smoke cessation?	Yes No

No

Chose not to answer

COMMENTS

Toileting

How well can you manage using the toilet?* Would you say that you: 00 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Subjective Evaluation of Health

Overall, would you rate your physical health as excellent, good, fair, or poor? * 00 - No response

- Poor

- Fair

- Good

-Excellent

12 - Chose not to answer

COMMENTS

What do you consider your primary concern in terms of your medical health and/or emotional health?

Physical Health (check all that apply)

None, I am physically healthy

I would like help managing this condition:

Chronic Bronchitis or Chronic Obstructive Pulmonary Disease (COPD)	Yes	No Asthma	Yes	No

Heart Failure	Yes	No

Chest Pain (angina)	Yes	No

High Blood Pressure	Yes	No

Seizures	Yes	No

Kidney Disease with or without dialysis	Yes	No Infectious Disease such as HIV/AIDS, Hepatitis, Tuberculosis (TB)	Yes	No

Preventive Care (check all services you have received in the past year)

Flu Vaccine Annual Physical

Mammogram (women)

Cervical Cancer Screening (women) Prostate Cancer Screening (men) Colonoscopy

Glaucoma Screening

COMMENTS

Hearing

How is your hearing?*

00 - No hearing impairment or impairment corrected with hearing aides 01 - Hearing difficulty at level of conversation

02 - Hears only very loud sounds 03 - No useful hearing

04 - Not determined

12 - Chose not to answer

COMMENTS

Memory

How well would you say that your memory is?

-Excellent

- Good

- Fair

- Poor

- Unable to answer 05 - Chose not to answer

Communication

How well would you say that you are able to communicate your needs or concerns to your providers (for example, in-home providers, medical providers, mental health providers)? *

00 -Excellent, no issues

05 - Good, I feel confident I am communicating well most of the time 06 - Fair, I am able to communicate some but not all needs or concerns 07 - Poor, I have many issues in communicating needs or concerns

08 - Unable to answer 12 - Chose not to answer

How confident are you that you can talk to your doctor or mental health provider about your concerns even when he or she does not ask?

- Very confident

-Somewhat confident, my level of comfort depends on my provider

-Somewhat confident, my level of comfort depends on the topic or concern 03 - Not confident, I have a difficult time talking to my providers

04 - Chose not to answer

Vision

How is your vision?*

00 - No impairment of vision or impairment but corrected with glasses, contacts 01 - Difficulty seeing at level of print

02 - Difficulty seeing obstacles in environment 03 - No useful vision

12 - Chose not to answer

COMMENTS

Phone Calling

Do you need assistance with making a phone call?* 01 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Shopping

Do you need assistance when you go shopping for food and other things you need? * 01 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Meal Preparation

Do you need assistance in preparing meals for yourself?* 01 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Light Housekeeping

Do you need assistance with light housekeeping, like dusting or sweeping? * 01 - Need no assistance

- Yes, needs assistance, met by current supports or help from others or equipment

COMMENTS - Yes, needs assistance NOT met by current supports or help from others or equipment 12 - Chose not to answer

Managing Medications

How comfortable are you in setting up your medications and remembering to take them?

01 - Need no help or supervision 05 - Don't take medications

- Only need someone to set up my medicine (need medication setup only)

- Only need someone to remind me to take medications(need verbal or visual reminders only) 08 - Need medication setups and reminders

COMMENTS MEDICATION LIST 09 - Need someone to help me take them (need medication setups and administration) 12 - Chose not to answer

Insulin Dependent

Are you diabetic? If yes, how do you control your diabetes? (Required for SNBC members*)

- Not diabetic

- No insulin required; diet controlled only 03 - Oral medications

04 -Sliding scale insulin and oral medications 05 -Scheduled daily insulin

06 -Scheduled daily insulin plus daily sliding scale

COMMENTS

Money Management

Do you need assistance with important paperwork such as Medical Assistance renewals? * 01 - Need no assistance

- Yes, needs assistance, met by current supports or help from others

- Yes, needs assistance NOT met by current supports or help from others 12 - Chose not to answer

Transportation

Do you need transportation assistance with any of the following: Medical, Dental, Behavioral Health appointments or obtaining medications at the pharmacy?*

01 - Need no assistance

- Yes, needs assistance, met by current supports or help from others

COMMENTS - Yes, needs assistance NOT met by current supports or help from others 12 - Chose not to answer

What mode or modes of transportation to you rely on most often? (check all that apply)

Own vehicle

COMMENTS Public transportation or bus Specialized transportation Other

Falls

Have you experienced any falls in your home or while out in the community? * 00 - No

- Yes, they've fallen but it wasn't in the last 12 months and/or didn't result in fracture

- No, but you have a concern about your balance or falling affect your daily activities or access to the community

03 - Yes, and a fall resulted in a fracture within the last 12 months – how did that happen?

Hospital/Nursing Home

In the past year, have you stayed overnight or longer in a hospital? * Yes – how many times?	Why?

No

In the past year, did you go to a hospital emergency room?* Yes – how many times?	Why?

No

In the past THREE years, have you spent time in a nursing facility? * Yes – how many times?	Why?

No

Sexual Activity

Are you sexually active? (Required for SNBC members*)

Y- Yes N - No

C- Chose not to answer

Do you have any family planning needs? (Required for SNBC members*)

Y- Yes N - No

C- Chose not to answer

Advance Directives

Is there an Advance Directive or Health Care Directive in place?

Yes No

Was Advance Directive/Health Care Directive discussed?

COMMENTS Yes No

Pain Screening

Are you experiencing any pain now or in the last two weeks?

Yes No

Has your pain affected your function or quality of life (e.g., activity level, mood, relationships, sleep or work)?

Yes No

How often do you experience pain?

Constantly Daily

Once a week Not often

At its worst, how severe is your pain (1 to 10 with 10 being the worst)?

Have you talked to your doctor or someone else about the cause of your pain? Yes – who?	When?

No

Have you talked to someone about how to handle your pain?

Yes – who?	When?

No

PAIN MANAGEMENTPLAN/COMMENTS

Safety

Is anyone currently mismanaging your money or stealing from you?

Yes No

Chose not to answer

Is anyone currently hurting you physically (hitting, slapping, pushing, kicking)?

Yes No

Chose not to answer

Is anyone currently touching you in a way that makes you feel uncomfortable?

Yes No

Chose not to answer

Is anyone currently emotionally abusive to you?

Yes No

Chose not to answer

Section D

Assessment Results* (For care coordinator's use) 35 - MSC+, MSHO or SNBC health risk assessment 39 -Refusal of the health risk assessment

50 - Person not located for the health risk assessment 98 - Care Coordinator change

Effective Date of Assessment*

Relocation from Nursing Home*

If you currently live in the nursing home or ICF-DD do you want to relocate to the community?

Yes No

Chose not to answer

Section F

Program Type* (For care coordinator's use)

18 - MSC+ or MSHO

28 -SNBC

NOTES

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